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Pittston Playground Program
-Week Two Registration-
JUNE 23-27, 2025
Parent/Guardian First name
*
Parent/Guardian Last name
*
Parent/Guardian Email
*
Parent/Guardian Phone
*
Parent/Guardian Address
*
How many children are you enrolling in the program?
*
1
2
3
Child 1 Full Name
*
Child One Birthday
*
Month
Day
Year
Child 1 Gender
*
Male
Female
Child 1 Medical Conditions/Allergies
*
Is child 1 allowed to walk home
*
Yes
No
Child 2 Full Name
Child 2 Birthdate
Child 2 Gender
Male
Female
Child 2 Medical Conditions/Allergies
Is child 2 allowed to walk home
Yes
No
Child 3 Full Name
Child 3 Birthdate
Child 3 Gender
Male
Female
Child 3 Medical Conditions/Allergies
Is child 3 allowed to walk home
Yes
No
Full name of additional emergency contact:
*
Telephone # for additional emergency contact:
*
Playground Program Payment
*
Price Per Child
$
25
Submit
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